Motivational Interviewing (MI)

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Motivational interview;

Homeless veterans;

Treatment retention;

Wait-list attrition

1. Introduction

Motivational Interviewing (MI) is an empirically supported, brief intervention. It is a client centered, directive treatment that increases intrinsic motivation to change by eliciting and resolving ambivalence and by eliciting and reinforcing the client's statements about his or her reasons, desire, ability, need and commitment to change (Miller and Rollnick, 1991 and Miller and Rollnick, 2002). The principles of MI emphasize the importance of supporting client self-efficacy for making the changes the client chooses to make. Motivational interventions, particularly those that include assessment feedback (motivational enhancement therapies (MET)), have been shown to be effective for both drug and alcohol related problems in several meta-analyses and reviews ( HYPERLINK "" \l "bib0100" Hettema et al., 2005, Burke et al., 2003, HYPERLINK "" \l "bib0195" Vasilaki et al., 2006, Dunn et al., 2001, Britt et al., 2003 and Miller and Wilbourne, 2002).

Clinical trials indicate that MI improves engagement, retention and outcome when added to traditional substance use treatment. Randomized trials testing MET (13 sessions) added to standard substance abuse treatment have shown MET to prime treatment by increasing treatment initiation, retention, and outcomes. For example, a single session of MET led to improved treatment engagement and decreased substance use in adolescents (Aubrey, 1998). Individuals entering outpatient substance use treatment, given an intake session delivered in a motivational style (without assessment feedback of MET), exhibited better treatment engagement than did those who received the standard intake (Carroll et al., 2001). Residents in an alcohol treatment program, given a two session assessment and an MI style assessment feedback interview, participated more fully in treatment and showed reduced alcohol consumption at three months post-intervention (Brown and Miller, 1993). Individuals using heroin, who received a three session MET intervention, showed improved outpatient treatment retention when compared to similar patients who did not receive the motivational component ( HYPERLINK "" \l "bib0185" Secades-Villa et al., 2004). Veterans attending outpatient treatment for alcohol use disorders, who received an additional 2 h of assessment and a 1 h MET session, had better three-month outcomes than control subjects who received the same assessment with an attentionplacebo interview (Bien et al., 1993).

MI has been less frequently tested in the most severely dependent populations and in those with co-occurring mental health concerns. Debate has arisen in the literature regarding how useful brief interventions, specifically MI, are in such populations. Moyer et al. found in their meta-analysis of studies comparing brief interventions with control conditions, in non-treatment seeking samples (e.g., primary care settings), that effect sizes were larger if participants with more severe alcohol problems were excluded (Moyer et al., 2002). However, there is growing evidence for the effectiveness of MI in individuals who have severe substance use problems. Bien et al. demonstrated the efficacy of a 1 h session of MI in alcohol dependent VA outpatients who were drinking over 90 standard drinks per week. Those receiving the intervention demonstrated better outcomes on a composite variable consisting of total standard drinks, peak blood alcohol level and percent days abstinent (Bien et al., 1993). Also, in a study of pregnant women who were recruited from a medical setting, Handmaker et al. observed a larger effect of a 1 h session of MI in those who initially had higher blood alcohol levels, one indicator of severity ( HYPERLINK "" \l "bib0090" Handmaker et al., 1999). In those with co-occurring mental health concerns, a series of brief MET sessions led to improved substance use outcomes in individuals diagnosed with psychoses (Kavanagh et al., 2004). A two session MI intervention that included personalized feedback for patients diagnosed with psychoses led to mixed results, with the MI group having better substance use treatment outcomes in HYPERLINK "" \l "200019088" cocaineusers but with the standard psychiatric interview having better outcomes in the marijuana users (Martino et al., 2006). In sum, the literature suggests that motivational interventions may be helpful in those with more severe substance use concerns and in those with co-occurring mental health concerns.

It is consistently demonstrated in the literature that more time in treatment correlates with better long-term outcome ( HYPERLINK "" \l "bib0060" Condelli and Hubbard, 1994, Greenfield et al., 2004, Harris et al., 2005, Simpson et al., 1999, HYPERLINK "" \l "bib0200" Welte et al., 1981 and HYPERLINK "" \l "bib0205" Zarkin et al., 2002), and the first step is treatment engagement. Individuals most in need of intensive substance abuse treatment (e.g., homeless, substance dependent, unemployed, co-occurring mental health concerns) often experience the most difficulty accessing care (Romeo, 2005). These individuals frequently encounter logistical problems, such as lack of access to information, limited transportation options or difficulty accessing a telephone. Homeless individuals often have little to no social support system, having exhausted their families patience and resources. There may be cultural and other social influences that are not supportive of individuals seeking help (Christian and Abrams, 2003). In addition, many residential programs have wait-lists, due to demand exceeding availability (Humphreys et al., 1988). In light of these numerous potential obstacles to accessing treatment and the importance of retention in treatment, interventions that increase engagement and retention in homeless individuals may be particularly important. A brief intervention that improves treatment engagement and length of stay (LOS) in a homeless population with complex challenges could be a valuable, cost-effective addition to treatment programs. This study focused on an MI interview that was delivered in one session. The intervention was conducted without assessment or assessment feedback, to reduce the barriers to implementation that multiple sessions, lengthy assessment or assessment feedback might pose when working with a transient population or when implementing into routine clinical care.

1.1. Objectives and hypotheses

This study investigated whether a single session of MI without feedback during the screening process could facilitate meeting waitlist requirements, increase program entry, and support program retention in a population of homeless veterans. The MI intervention was hypothesized to increase program admission, LOS, completion and graduation, as compared to the standard (Std) condition. As MI was developed to increase readiness to change and self-efficacy, it was hypothesized that readiness and self-efficacy would change as a result of the interview.

2. Methods

2.1. Setting

The Homeless Veterans Rehabilitation Program (HVRP), of the VA Palo Alto Health Care System (VAPAHCS), is a 180-day, residential, domiciliary care program for homeless veterans. Applicants to the program are homeless, substance dependent, and predominantly unemployed, disenfranchised, and with social and relational difficulties.

2.2. Program eligibility

When veterans apply to the program, they are screened by a social worker for program eligibility; the veteran must be capable of self-care, homeless or at risk of homelessness, free of significant medical, psychological or legal problems that would interfere with residential treatment, and willing and able to return to work. Eligible veterans are placed on a wait-list and given a tentative admission date.

2.3. Wait-list compliance requirements

The wait-list can be challenging for this population. Wait-listed veterans may be required to obtain medical clearance or to resolve pending legal issues. During the wait-list period, potential participants are instructed to call in every day, Monday through Friday, to check bed availability, and to abstain from substance use for at least 72 h prior to entry. These all require some motivation and initiative on the part of the veteran.

2.4. Reasons veterans can be removed from the wait-list

Veterans can be removed from the wait-list if they neglect to call for five consecutive weekdays, or fail to obtain the necessary clearances; however, entry requirements are somewhat flexible, e.g., in the case of someone whose urine is positive but who has otherwise met entry requirements, the veteran may be admitted but stabilized before full program participation.

2.5. Participants

Participants were enrolled in the study from May 2004 through September 2005. The number of participants enrolled was determined by veteran and study personnel availability. Baseline and demographic characteristics are reported in Table 1.

Table 1.

Demographics and baseline characteristics.

Demographic MI Group

Std Group

M SD Range M SD Range

Agea45.86 5.15 3656 48.52 7.05 3862

% of MI Group % of Std Group

Genderb95% male 100% male

Ethnicityb African American 63% 41%

Caucasian 34% 47%

Hispanic 2.4% 8.8%

Native American 0% 2.9%

Living situationb Family/Friends...

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